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More Evidence That ED Crowding Harms Patients

The December 2011 issue of Academic Emergency Medicine is dedicated to the proceedings of a consensus conference on emergency department (ED) crowding. Several articles in the issue address the effect of ED crowding and boarding on patient care and outcomes.
In a retrospective study of 41,256 patients admitted to an academic hospital from the ED, Singer and colleagues found that mortality and hospital length of stay increased significantly with increasing ED boarding time. In analysis that controlled for comorbidities, mortality increased from 2.5% in patients boarded for <2 hours to 4.5% in patients boarded for 12 hours. Mean hospital stay increased from 5.6 days for those boarded for <2 hours to 8.7 days for those boarded for 12 hours.
Sills and colleagues retrospectively evaluated the effectiveness and timeliness of analgesia delivery for long-bone fractures in 1229 patients (age range, 021 years) at a children's hospital ED. When crowding was at the 90th percentile, compared with the 10th percentile, patients were as much as 47% less likely to receive timely analgesia and as much as 17% less likely to receive effective analgesia. Quality declined most steeply between the 75th and 90th percentiles of crowding.
In a retrospective study of 190 febrile neonates evaluated at a single pediatric ED, Kennebeck and colleagues found that time to first antibiotic administration ranged from 18 to 397 minutes (mean, 182 minutes). ED crowding was significantly associated with delays to antibiotic administration. The measure of crowding that was most strongly associated with delays was time from patient arrival to ED room placement.
In a retrospective study by Liu and colleagues of 1431 patients admitted to two academic hospitals with chest pain, pneumonia, or cellulitis, measurement of cardiac enzymes in chest pain patients was less likely to be delayed in boarded patients than nonboarded patients. Boarding time was not associated with delays in antibiotic delivery or measurement of partial thromboplastin time (for patients on heparin), medication errors, or adverse events but was associated with delay in administration of home medications.
Comment: Emergency department crowding is a public health catastrophe. Where else in our healthcare system would we accept a "process" that doubled mortality? Hospitals often paint this as just an ED problem, but The Joint Commission has caught on, with new standards reflecting time from admission decision to placement in an inpatient bed. Hopefully, change is on the way. The status quo in many of our nation's hospitals is simply not acceptable. Studies like these are crucial for awakening hospital administration to address ED crowding on an institutional level.